(RN) Manager - Utilization Management - 142006

UC San Diego Health; San Diego (CA); On-site; USD 160,000 - 200,000; Full time

Job summary

UC San Diego Health seeks a Manager of Utilization Management to supervise Nurse Case Manager and Referral Coordinator staff handling UM operations for commercial and Medicare Advantage members within UC San Diego Health IPA and its HMO Health Plans.

This role focuses on inpatient utilization management in a managed care/IPA setting, incl. oversight of delegated UM functions and regulatory compliance. Strong leadership and prior authorization expertise are essential.

Qualifications

• Bachelor's degree in nursing and California RN licensure.
• Five+ years of relevant experience including 3–5 years in IPA/MSO or Health Plan/HMO.
• Experience with Commercial and Medicare lines of business.
• Strong prior authorization review experience.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation, compliance, risk, appeals, and grievances.
• Proven ability to supervise a team and manage complex workflow and priorities.

Responsibilities

• Oversees day-to-day department operations, schedules staff, and covers team duties as needed.
• Escalates complex cases for Medical Director review or UP/Director when necessary.
• Leads case management with clinical and nonclinical staff across referral processes.
• Collects and reports data on UM processes, vendor relationships, and regulatory compliance.
• Works with management to develop new UM processes and programs.
• Coaches staff and participates in hiring, salary actions, and performance reviews.
• Ensures orientation and ongoing training for new staff; communicates policy updates.
• Implements new methods, systems, and processes.

Skills

Leadership / Supervisory experience

Prior authorization review

Communication skills

IPA/MSO knowledge

Epic / EHR familiarity

Regulatory/compliance knowledge

Education

Bachelor's degree in nursing

Registered Nurse (CA)

Tools

Epic

MCG

Job description

Payroll Title

CASE MGT HC SUPV 2

Department

PHSO - CLINICAL OPERATIONS

Hiring Pay Scale

$160,000 - $200,000 / Year

Worksite

Greenwich Drive

Appointment Type

Career

Appointment Percent

100%

Union

Uncovered

Total Openings

1

Work Schedule

Days, 8-Hour Shift, Monday-Friday

#142006 (RN) Manager - Utilization Management

Filing Deadline

Tue 11/10/2026

Description

The Manager of Utilization Management supervises Nurse Case Manager and Referral Coordinator staff responsible for managed care utilization management (UM) operations for commercial and Medicare Advantage members under UC San Diego Health IPA and its HMO Health Plans. This position focuses on inpatient utilization management within a managed care/IPA environment, including oversight of delegated UM functions and compliance with applicable regulatory requirements and health plan delegation standards.

Key Responsibilities

• Oversees and coordinates day-to-day department operations, schedules staff to ensure adequate coverage, prioritizes UM team workload and assignments, covers team member duties as needed, resolves system issues, advises on work methods, functions as a resource, and assists with prior authorizations and inpatient utilization review (UR)/discharge planning. Escalates complex cases as needed for Medical Director review or to the Assistant Director of UM/Director of PHSO.
• Coordinates and/or leads case management teams with a variety of clinical and nonclinical staff to review specific routine, expedited, and complex cases, optimize house guidelines and scope of practice, and evaluate options for quality and efficiency along the referral determination process.
• Collects, analyzes, and reports data on UM processes and results, including in-network vendor relationships and adequacy, referrals, resource management, delegated UM operations, and regulatory compliance.
• Collaborates with management on operational and performance issues and the development of new processes and programs to improve UM systems and processes.
• Coaches and evaluates team members and participates in decision-making on hiring, salary actions, terminations, performance ratings, and other human resources matters.
• Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
• Ensures adequate orientation, training, and mentoring of new staff. Keeps staff and patient care teams informed of changes and updates in processes, technology, regulations, and quality standards. Provides guidance and instructions on UM updates to processes, procedures and clinical guidelines/policies.
• Implements new methods, systems, and processes.
• Other duties as assigned.

Minimum Qualifications

• Bachelor's degree in nursing.
• Registered Nurse in the state of California.
• Five or more years of relevant experience; experience must include 3-5 years of experience within IPA/MSO or Health Plan/HMO.
• Experience with Commercial and Medicare lines of business.
• Strong hands-on experience with prior authorization review process.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals, and grievances.
• Experience and proven success in ability to effectively supervise a team and managing the complex workflow and multiple priorities.
• Must have excellent skills to communicate and influence effectively with all levels of staff, physicians, patients, and external constituents, both verbally and in writing.
• Solid technology skills with ease of use of all programs (such as EPC, mcg) and an ability to prioritize multiple tasks in a fast-paced environment.

Preferred Qualifications

• Previous UM experience working for an IPA/MSO or Health Plan/HMO in a managerial/supervisor role.
• Thorough understanding of Health Plan delegation, financial responsibility, and medical necessity for referral processing using evidence-based tools.

SPECIAL CONDITIONS

• Employment is subject to a criminal background check and a pre-employment physical.
• Must be able to work various hours and locations based on business needs. Availability weekend/holidays as needed
• Hybrid Schedule: The candidate selected will work in the office 1-2 days per week once you complete initial orientation. Additional onsite days may be required based on department and business needs.

Pay Transparency Act

Annual Full Pay Range: $136,600 - $267,600 (will be prorated if the appointment percentage is less than 100%)

Hourly Equivalent: $65.42 - $128.16

Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).

Vaccination Programs

If employed by the University of California, you will be required to comply with our Policy on Vaccination Programs, which may be amended or revised from time to time. Federal, state, or local public health directives may impose additional requirements.

Life-support certifications

If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and dozens of outpatient clinics. We invite you to join our team!

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

For the University of California’s Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.

Misconduct Disclosure Requirement

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.

• "Misconduct" means any violation of the policies governing employee conduct at the applicant’s previous place of employment, including, but not limited to, violations of policies prohibiting sexual harassment, sexual assault, or other forms of harassment, or discrimination, as defined by the employer. For reference, below are UC’s policies addressing some forms of misconduct:
• UC Sexual Violence and Sexual Harassment Policy
• UC Anti-Discrimination Policy
• Abusive Conduct in the Workplace